A population-based study of the association between pathological gambling and attempted suicide

Introducing and Evaluating the Effectiveness of Online Cognitive Behavior Therapy for Gambling Disorder in Routine Addiction Care: Comparative Cohort Study

BACKGROUND

Several treatment-related challenges exist for gambling disorder, in particular at-scale dissemination in health care settings.

OBJECTIVE

This study describes the introduction of a newly developed internet-delivered cognitive behavioral therapy (iCBT) program for gambling disorder (GD), provided with therapist support in routine addiction care, in a nationally recruited sample in Sweden. The study details the introduction of the iCBT program, evaluates its effectiveness and acceptability, and compares registry outcomes among iCBT patients with other patients with GD at the clinic who received face-to-face psychological treatment as usual.

METHODS

The study site was the Stockholm Addiction eClinic, which offers digital interventions for addictive disorders in routine care. The iCBT program was introduced nationally for treatment-seeking patients through the Swedish eHealth platform. After approximately 2 years of routine treatment provision, we conducted a registry study, including ordinary patients in routine digital care (n=218), and a reference sample receiving face-to-face psychological treatment for GD (n=216).

RESULTS

A statistically significant reduction in the Gambling Symptom Assessment Scale scores during the treatment was observed (B=-1.33, SE=0.17, P<.001), corresponding to a large within-group Cohen d effect size of d=1.39. The iCBT program was rated high for satisfaction. A registry-based survival analysis, controlling for psychiatric comorbidity, showed that patients receiving iCBT exhibited posttreatment outcomes (re-engagement in outpatient addiction care, receiving new psychiatric prescriptions, enrollment in psychiatric inpatient care, and care events indicative of contact with social services) similar to comparable patients who underwent face-to-face treatment-as-usual.

CONCLUSIONS

A lack of randomized allocation notwithstanding, the iCBT program for GD evaluated in this study was well-received by patients in routine addiction care, was associated with the expected symptom decrease during treatment, and appears to result in posttreatment registry outcomes similar to face-to-face treatment. Future studies on treatment mechanisms and moderators are warranted.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s40814-020-00647-5.

Internet-delivered therapist-assisted cognitive behavioral therapy for gambling disorder: a randomized controlled trial

Objectives

Cognitive behavioral therapy (CBT) is the most promising treatment for gambling disorder (GD) but only 21% of those with problematic gambling seek treatment. CBT over the Internet might be one way to reach a larger population. The aim of this study was to assess the effectiveness of Internet-delivered CBT with therapist guidance compared to an active control treatment.

Methods

Using a single-blinded design, 71 treatment-seeking gamblers (18-75 years) diagnosed with GD were randomized to 8 weeks of Internet-delivered CBT guided by telephone support, or 8 weeks of Internet-delivered motivational enhancement paired with motivational interviewing via telephone (IMI). The primary outcome was gambling symptoms measured at a first face-to-face assessment, baseline (treatment start), every 2 weeks, post-treatment, and 6-month follow-up. Gambling expenditures, time spent gambling, depression, anxiety, cognitive distortions, and quality of life were assessed as secondary outcomes. Analysis was performed on the full analysis sample (n = 60), with intention-to-treat sensitivity analyses (n = 69).

Results

In the CBT group, 80% stayed in treatment until the final week, compared to 67% in IMI. Post-treatment and at 6-month follow-up, no differences were found between CBT and IMI for any outcome measure. An exploratory analysis of the total sample (n = 60) showed a significant effect of time during treatment on gambling symptoms (d, [95% CI] 0.52, [-1.15, 2.02]) and all secondary outcomes except the gambling diary (depression (0.89, [-1.07-2.65]); anxiety (0.69, [-1.20-2.38])); cognitive distortions (0.84, [-0.73-2.29]); quality of life (0.60, [-0.61-1.70])). Post-treatment, there were no clinical gambling symptoms in either group. Some deterioration was seen between post-treatment and 6-month follow-up on gambling symptoms (0.42, [-1.74-2.43]), depression (0.59, [-0.82-1.86]), and anxiety (0.30, [-0.99-1.48]). Additionally, it was observed that the largest reduction in gambling symptoms was between the first assessment and baseline.

Conclusion

Both treatments offered in this study were effective at reducing gambling symptoms. It is also possible that the process of change started before treatment, which gives promise to low-intensity interventions for GD. Additional research is needed as this approach could be both cost-effective and has the potential to reach more patients in need of treatment than is currently possible.

Clinical trial registration

https://www.isrctn.com/, identifier ISRCTN38692394.

Suicidal Behaviors and Associated Factors Among Individuals with Gambling Disorders: A Meta-Analysis

The risk for suicidal behaviors including suicide ideations and attempts among individuals with gambling disorder (IWGDs) is high compared to the general population. Little is known about the interplay of mood disorders, alcohol use disorders, and suicidal behaviors among IWGDs. The study aimed to determine the prevalence, sociodemographic characteristics, risky behaviors, mental health disorders, and alcohol use disorders associated with suicide behaviors among IWGDs. Studies published between January 1 1995 and September 1 2022 were obtained from following databases: PubMed, Scopus, Web of Science and Cochrane Library databases. PECOS (population, exposures, comparison, outcome, and study design) criteria were used for selecting studies. The Newcastle-Ottawa Scale (NOS) was used for assessing risk of bias and rated each study in terms of exposure, outcome, and comparability. After initial assessment of 10,243 papers, a total of 39 studies met the eligibility criteria. Among IWGDs, the findings indicated a life-time pooled prevalence rate of 31% for suicide ideations (95% CI, 23-39%), 17% for suicide plans (95% CI, 0-34%), and 16% for suicide attempts (95% CI, 12-20%). Generally, suicide ideations among IWGDs were associated with having any financial debt and having chronic physical illnesses, as well as experiencing depression, mood disorders, and alcohol use disorders. Suicide attempts among IWGDs were associated with being older and having a childhood history of sexual abuse, as well as experiencing depression, mood disorders and alcohol use disorders. Interventions can help to facilitate seeking support among IWGDs by de-stigmatizing mental health disorders as well as improving the quality of care presented to individuals with psychiatric conditions.

Gambling-related suicides and suicidality: A systematic review of qualitative evidence

The relationship between gambling and suicides or suicidality has received much research attention in recent years. Review studies have already mapped the quantitative occurrence of suicide attempts, suicides, and self-harm among gamblers, and found a positive association. Related comorbidities and conditions have also been charted in previous reviews. However, there is still a gap in knowledge regarding the actual processes that connect gambling and suicidal behavior. To understand these processes, the current paper conducts a systematic review of qualitative evidence on gambling-related suicides and suicidality. The aim was to identify the role of gambling as well as of confounding factors in suicidality, and what kind of support suicidal individuals have received or would need. We searched for relevant literature in seven scientific databases. We included all studies that presented empirical qualitative evidence on gambling-related suicide, suicidality and/or self-harm (N = 20). The results show two main processes that connect gambling and suicidal behavior: indebtedness and shame. At the same time, suicide is a multifactorial phenomenon, and related to other confounding factors. These include psychiatric conditions, personality traits, and life conditions. In many cases, these appear to emerge as a consequence of gambling. Treatment for suicidality has been effective in some cases, but indebtedness and shame may also function as barriers to help-seeking. We conclude that effective prevention is needed by adapting a more comprehensive public health approach and population-level interventions.

What to target in cognitive behavioral treatment for gambling disorder-A qualitative study of clinically relevant behaviors

BACKGROUND

From a clinical perspective, knowledge of the psychological processes involved in maintaining gambling disorder has been lacking. This qualitative study formulated hypotheses on how gambling disorder is maintained by identifying clinically relevant behaviors at an individual level, as a means to guide the development of new cognitive behavioral interventions.

METHODS

Six individuals from a treatment study, diagnosed with gambling disorder and with diverse symptom profiles of psychiatric comorbidity, were recruited. Participants were interviewed using an in-depth semi-structured functional interview and completed self-report measures assessing gambling behavior.

RESULTS

Functional analysis was used as a theoretical framework for a thematic analysis, which yielded the following categories: 1) antecedents that may increase or decrease gambling; 2) experiences accompanying gambling; 3) control strategies; 4) consequences of gambling behavior; and 5) events terminating gambling behavior. Few differences were identified in relation to symptom profiles of psychiatric comorbidity, although some gamblers did not report experiencing abstinence when not being able to gamble.

CONCLUSIONS

Gambling is a secluded activity mainly triggered by access to money. Positive and negative emotions could be both antecedents and functions of gambling behavior. Avoidance-based strategies used to control gambling might result in a failure to learn to control gambling behavior. Anticipation, selective attention, and chasing could be important reinforcers, which should be addressed in new developments in cognitive behavioral treatment for gambling disorder.

Gambling-related suicide in East African Community countries: evidence from press media reports

Background

Gambling activities and associated mental health problems have become a topic of increased concern globally. Many individuals with a severe gambling disorder have gambling-related suicidality. However, no study has explored gambling-related suicide in East African Community (EAC) countries. The present study investigated the press media reporting of gambling-related suicide cases from EAC countries.

Methods

As there is no established suicide database in that region, media reports were utilized to collect gambling-related suicide data. Gambling-related suicide case reports were searched for in EAC countries’ press media websites using Google. After removing duplicates, a total of 18 suicides were found.

Results

The victims were all males aged 16 to 40 years. The most prevalent reason for the death was university students who had used their university tuition fees for gambling and losing the money (n = 4/17). All the suicide deaths were in Kenya (10/18), Uganda (7/18), and Tanzania (1/18). Betting on soccer was the most common type of gambling reported (n = 11/15), and hanging was the most used mode of suicide (n = 10/16).

Conclusions

Based on the press media reports, 18 males were identified as having carried out gambling-related suicides. The countries with the most widespread opportunities to gamble had more gambling-related suicides, although the number of suicides was very small.

The Association Between Problem Gambling and Suicidal Ideations and Attempts: A Case Control Study in the General Swedish Population

The association between problem gambling and suicidal behaviours is well established in treatment seeking populations, but less explored among sub-clinical problem gamblers in the general population. The aim of this study was to examine the association between problem gambling (including moderate risk gambling) and suicidal ideations/suicide attempts, in the general Swedish population. Another aim was to compare problem gamblers with and without suicide ideation/attempts. A case-control study nested in the Swelogs cohort was used. Both ideations and attempts were about twice as frequent among the cases compared to the controls. After controlling for socio-economic status and life-time mental health problems, suicidal ideation, but not attempts, remained significantly higher among the cases compared to the controls. The largest difference between attempters and non-attempters were on payment defaults and illicit drug abuse, whereas depression yielded the largest difference between ideators and non-ideators. Problem gambling severity (PGSI 8+) resulted in the smallest difference, compared to the other variables, between attempters and non-attempters. Even though no conclusion regarding the casual relationship can be drawn in this type of study, it seems like sub-clinical levels of problem gambling might have an impact on suicidal ideations whereas for suicide attempts to occur, other factors need to be present. In addition to mental health issues, financial difficulties may be such factors.

Gambling Disorder in an Italian Population: Risk of Suicide Attempts and Associated Demographic-Clinical Factors using Electronic Health Records

To identify the demographic and clinical characteristics associated with access to Emergency Departments for Suicide Attempt in a cohort of patients with Gambling disorders. We used electronic health records of inpatient and outpatient services to identify individuals who received a diagnosis of gambling disorder (ICD-9 or ICD-10 codes) in the Metropolitan area of Bologna from 2009 to 2019. In this cohort we identified accesses to Emergency Departments for suicide attempt through cross-matching with electronic records. We calculated Crude Suicide Attempt Rates; we also included the demographic-clinical variables in a multivariate Poisson regression. We identified 692 patients with a diagnosis of gambling disorder and a total of 2733 Person Years. The Crude Suicide Attempt Rate per 1000 Person Years was 9.17 (95% CI 6.20-13.58), higher for females and much higher than the general population (incidence rate ratio = 93.72). The multivariate analysis showed a higher risk of suicide attempt in the year following the first contact with a clinical service, in patients younger than 45 years, with alcohol use disorders and personality disorders. This study evidenced a high risk of access to Emergency Departments for suicide attempt in individuals with a diagnosis of gambling disorder and highlighted important demographic and clinical factors that should be considered when evaluating suicide risk in this population.

Gambling in patients with major depressive disorder is associated with an elevated risk of Suicide: Insights from 12-years of Nationwide inpatient sample data

BACKGROUND

There is a frequent occurrence of gambling disorder (GD) in patients with major depressive disorder (MDD). Psychiatric comorbidities can present more severely in patients diagnosed with pathological gambling. There is limited information on symptom trends in MDD patients with GD, particularly in association with suicidality.

OBJECTIVES

Our primary aim was to compare baseline characteristics in MDD patients with and without a GD diagnosis. The secondary aim was to assess the rate of suicidality (suicidal ideation/attempt) between groups and evaluate any predictors that may be associated with an increased risk of suicidal behavior. In addition, we also assessed the variation in gambling trends in MDD patients over several years.

METHODS

Data for the study were obtained retrospectively from the Nationwide Inpatient Sample (NIS) dataset for the years 2006-2017. Our primary patient cohort was composed of patients age ≥ 18 years; admitted to the hospital with a primary diagnosis of MDD and a secondary diagnosis of GD. For baseline characteristics and suicidality, we compared these patients to MDD patients without a GD diagnosis. In addition, we also assessed the trends of baseline characteristics in MDD patients with GD over the years.

RESULTS

A total of 6646 patients were included in the MDD with GD group, and compared with 4,021,063 MDD patients without a GD diagnosis. More patients in MDD with GD group were older, white, and male. Alcohol abuse and obesity were seen more commonly in the GD group. In the outcome analysis, suicidal ideation (45.4% vs. 39.5%, p < 0.001), suicide attempt (7.2% v. 4.5%, p < 0.001) and composite of suicidal ideation/attempt (50.7% vs. 43.1%, p < 0.001) were more common in MDD with GD group compared to MDD without GD. In the multivariate analysis, GD was associated with higher odds of suicidality (Odds Ratio: 1.42 (1.35-1.49), p < 0.001). For the in-hospital trend analysis, we observed that, out of all MDD related admissions, comorbid GD related admissions decreased from 0.20% in 2006-2008 to 0.12% in 2015-2017. Among MDD patients with GD, there was an upward trend of inpatient admissions for non-white race, and Southern part of the United States (US) and a downward trend white race, and Western part of the US.

CONCLUSIONS

There is a higher risk of suicide, with an upward trend over the years in MDD patients with GD when compared to MDD patients without GD. Also, the prevalence of alcohol abuse was high in the GD group. Increased resource allocation and efforts to raise awareness campaigns for suicide prevention are needed to address the morbidity in this vulnerable patient population.

Internet-based cognitive behavior therapy for problem gambling in routine care: protocol for a non-randomized pilot and feasibility trial

Background

Problem gambling and gambling disorder are major public health concerns worldwide, and awareness of associated negative consequences is rising. In parallel, treatment demand has increased, and Internet interventions offer a promising alternative for providing evidence-based treatment at scale to a low cost.

Method

We developed a novel Internet-delivered cognitive behavioral treatment for gambling, based on qualitative interviews with treatment-seeking gamblers, behavioral research on gambling behavior, and the pathway model for problem gambling. This research protocol describes a non-randomized pilot and feasibility trial conducted in routine addiction care with adult treatment-seeking patients (max N = 25) with problem gambling. The primary aim is to ensure acceptability and safety, measured by satisfaction, credibility, working alliance, and possible negative effects. Secondary aims are feasibility of study procedures in terms of recruitment and measurement procedures as well as potential effectiveness measured weekly by gambling symptoms as primary outcome and gambling behavior, quality of life, symptoms of depression and anxiety, alcohol, and drug use as secondary outcomes. Potential mediators measured weekly are loss of control, verbal rules, and well-being.

Discussion

This study is innovative in several respects, regarding both treatment development and implementation. The results of the study will guide a future randomized controlled trial, as well as the development of the intervention and intervention implementation within ordinary addiction care.

Trial registration

Clinical trials.gov, NCT ID: NCT03946098. Registered 10 May 2019

Adolescents and loot boxes: links with problem gambling and motivations for purchase

Loot boxes are items in video games that can be paid for with real-world money but contain randomized contents. Many games that feature loot boxes are played by adolescents. Similarities between loot boxes and gambling have led to concern that they are linked to the development of problem gambling in adolescents. Previous research has shown links between loot boxes and problem gambling in adult populations. However, thus far, there is no empirical evidence of either the size or existence of a link between loot box spending and problem gambling in adolescents. A large-scale survey of 16- to 18-year-olds (n = 1155) found evidence for such a link (η 2 = 0.120). The link between loot box spending and problem gambling among these older adolescents was of moderate to large magnitude. It was stronger than relationships previously observed in adults. Qualitative analysis of text data showed that gamers bought loot boxes for a variety of reasons. Several of these motivations were similar to common reasons for engaging in gambling. Overall, these results suggest that loot boxes either cause problem gambling among older adolescents, allow game companies to profit from adolescents with gambling problems for massive monetary rewards, or both of the above. Possible strategies for regulation and restriction are given.

Recent Suicidal Ideation and Behavior in the General Population: The Role of Depression, Posttraumatic Stress, and Reactive Avoidance

The multivariate relationship between suicidality and three potential etiologic variables (depression, posttraumatic stress, and reactive avoidance) was examined in a stratified sample of 679 individuals from the general population. Lifetime exposure to a trauma or another very upsetting event was prevalent among those reporting suicidal behavior in the previous 6 months (58%) and those reporting recent suicidal ideation alone (40%), relative to those with no recent suicidal thoughts or behaviors (26%). Canonical correlation analysis indicated two independent sources of variance: the first loading on both suicidal ideation and behavior, predicted by depression, posttraumatic stress, and reactive avoidance, and the second indicating a unique relationship between suicidal behavior and reactive avoidance alone. Results indicate that the etiology of suicidality is likely multidimensional, and point to a significant variant of suicidal behavior that is unrelated to depression or posttraumatic stress, but may reflect emotional dysregulation and subsequent distress reduction behaviors.

Development of the Gambling Disorder Identification Test (G-DIT): Protocol for a Delphi Method Study

Background

Research on the identification and treatment of problem gambling has been characterized by a wide range of outcome measures and instruments. However, a single instrument measuring gambling behavior, severity, and specific deleterious effects is lacking.

Objective

This protocol describes the development of the Gambling Disorder Identification Test (G-DIT), which is a 9- to 12-item multiple-choice scale with three domains: gambling consumption, symptom severity, and negative consequences. The scale is analogous to the widely used Alcohol Use Disorders Identification Test (AUDIT) and the Drug Use Disorders Identification Test (DUDIT).

Methods

The G-DIT is developed in four steps: (1) identification of items eligible for the G-DIT from a pool of existing gambling measures; (2) presentation of items proposed for evaluation by invited expert researchers through an online Delphi process and subsequent consensus meetings; (3) pilot testing of a draft of the 9- to 12-item version in a small group of participants with problem gambling behavior (n=12); and (4) evaluation of the psychometric properties of the final G-DIT measure in relation to the existing instruments and self-reported criteria of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), among individuals with problem gambling and nonproblematic recreational gambling behaviors (n=600). This protocol article summarizes step 1 and describes steps 2 and 3 in detail.

Results

As of October 2018, steps 1-3 are complete, and step 4 is underway.

Conclusions

Implementation of this online Delphi study early in the psychometric development process will contribute to the face and construct validity of the G-DIT. We believe the G-DIT will be useful as a standard outcome measure in the field of problem gambling research and serve as a problem-identification tool in clinical settings.

International Registered Report Identifier (IRRID)

RR1-10.2196/12006

Gambling and Subsequent Road Traffic Injuries: A Longitudinal Cohort Analysis

BACKGROUND

To compare the risks of a road traffic injury (RTI) crash among adults who were involved in high-risk gambling and those who did not gamble.

METHODS

We conducted a linked longitudinal cohort analysis of adult persons in large population survey conducted during 2007 and 2008 in Ontario, Canada. We used responses to Problem Gambling Severity Index to distinguish persons as nongamblers, no-risk, low-risk, or high-risk gamblers. All persons were subsequently monitored for a subsequent RTI crash as a driver, pedestrian, or bicyclist up to March 31, 2014, through health insurance databases. We estimated relative risks as rate ratios (RRs) with 95% confidence intervals (95% CIs).

RESULTS

In all, 30,652 adults were included, of whom 52% self-identified as gamblers, including 49% as no-risk gamblers, 2% as low-risk gamblers, and 1% as high-risk gamblers. During a median follow-up period of 6.8 years, 708 participants (2%) were involved in 821 RTI crashes. The absolute risks of an RTI were 6.4 per 1000 person-years (95% CI 3.7-10.4) in high-risk gamblers and 3.6 per 1000 person-years (95% CI 3.2-4.0) in nongamblers. The relative risks for RTI crashes were significantly higher in high-risk gamblers than in nongamblers (adjusted RR 1.68, 95% CI 1.03-2.76). The risks for RTI crashes as a driver were augmented in high-risk gamblers than in nongamblers (RR 1.97, 95% CI 1.13-3.43).

CONCLUSIONS

We found an increased risk of an RTI crash among drivers who self-identified as high-risk gamblers. Further research exploring the underlying mechanisms of these associations might interest health professionals to monitor RTI risks in adults involved in high-risk gambling.

Understanding the Relationship Between Subjective Wellbeing and Gambling Behavior

This paper examines the relationship between gambling behavior and subjective wellbeing. It is often asserted that populations consist of different types of gamblers: those for whom gambling is a harmless leisure activity and those (pathological/problem gamblers) for whom the activity has harmful effects. One might, therefore, assume that subjective wellbeing will be negativity associated with an individual's level of gambling addiction. Alternatively, gamblers may choose to gamble because they derive utility from participating in this activity and so the relationship between happiness and gambling might be positively correlated. In this paper we test this association, empirically, using data from the 2010 British Gambling Prevalence Survey. The statistically significant findings from this analysis support the hypothesis that individual wellbeing falls as gambling disorder increases.

A Baseline Study of Past-Year Problem Gambling Prevalence Among Ohioans

Historically, the scope of legalized gambling was limited in Ohio, but everything changed when a new constitutional amendment allowed four casinos to open. To better understand the impact of gambling expansion, a household survey was commissioned to determine the baseline estimate of problem gambling behaviours in the state before casinos opened. Participants were selected through multi-stage probability sampling, with over 3,500 respondents completing valid surveys. Nearly 60% of Ohioans gambled in the past year, but the statewide prevalence of problem gambling was relatively low; only 1.4% of persons scored high enough on the Problem Gambling Severity Index to be classified as a potential problem gambler (score >3). Regional estimates of problem gambling were highest for Franklin and Hamilton counties (both 5.0%) and lowest for Lucas and Cuyahoga counties (3.2% and 2.1%, respectively). Exploratory logistic regression modelling found that race, employment, education, family history of problem gambling, and feelings of depression increased the odds of being a problem gambler. Results will inform the discussion about current gambling problems and enable policy makers to design prevention strategies.La présente étude portait sur la relation entre le prix des billets de loterie instantanée (à gratter) et la « récupération des pertes » dans un seul épisode de jeu. Pendant plusieurs mois, chaque fois qu’un billet de loterie instantanée était acheté (N = 1081), les commis de dépanneur consignaient le sexe des joueurs et le prix des billets de loterie instantanée, et indiquaient si le consommateur avait acheté un autre billet avant de quitter les lieux. L’analyse de régression logistique a montré une corrélation importante entre le prix des billets et le rachat (rapport de cotes = 0,842, p < 0,0001), ce qui suggère que la récupération au cours d’un même épisode de jeu est courante pour les billets de loterie instantanée à plus bas prix et que de plus faibles coûts ne réduisent pas nécessairement les risques.

Association of Pathological Gambling with Depression in Scotland

As most research concerning gambling and depression has been conducted on clinical populations, the present study examined the relationship between gambling and depression across a large sample in Scotland in higher education and the community. A questionnaire-based cluster design involved the distribution of the South Oaks Gambling Screen and the Centre for Epidemiologic Studies Depression Scale mainly to students and staff of higher educational establishments, with small community and gambling samples also included. Thirty-seven colleges and universities across Scotland participated in the research, with a sample of 2,259 people aged sixteen years of age or over ( M = 28.9 yr., SD = 13.4) being obtained. It was found that past-year probable pathological gamblers had significantly higher depression than problem gamblers, nonproblem gamblers, and nongamblers. However, when probable pathological gamblers who had sought treatment were omitted from the analysis, the nontreatment-seeking probable pathological gambling group no longer had significantly higher depression than the problem gambling group. Female problem and probable pathological gamblers had particularly high depressive symptomatology, suggesting comorbid depression may be a prominent feature of problematic female gambling.

Factors associated with suicidal risk among a French cohort of problem gamblers seeking treatment

Compared to general population, pathological gamblers are 3.4 times more likely to attempt suicide. Our objective was to identify specific profiles of problem gamblers (PGs) with suicidal risk according to sociodemographic, clinical and gambling characteristics. The PGs cohort, called "EVALJEU" , consists in the inclusion of any new PG seeking treatment in our Department. Patients underwent a semi-structured clinical interview and completed self-report questionnaires. The "suicidal risk module" of the Mini International Psychiatric interview (MINI) allowed to constitute two groups of patients that were compared, according to the presence of a suicidal risk. A logistic regression was performed to identify factors related to suicidal risk in PGs. In our sample (N=194), 40.21% presented a suicidal risk. A history of major depression and anxiety disorders were predictors of suicidal risk as well as the perceived inability to stop gambling. Suicidality is a significant clinical concern in PGs. Therefore, three specific predictors, identified by our study, must be assessed.

A dangerous cocktail: Alcohol consumption increases suicidal ideations among problem gamblers in the general population

The current research examined whether alcohol consumption exacerbates suicidal ideations among gamblers in the general population. While prior research suggests problem gambling severity and excessive alcohol consumption are unique predictors of suicidal behaviors, the extant literature as almost exclusively focused on gamblers in treatment. This represents a significant gap in the literature as less than 10% of gamblers seek treatment. Furthermore, gamblers in treatment are not representative of gamblers in the general population, precluding a simple generalization of research findings. We address this gap using data obtained from the Canadian Community Health Survey (Cycle 4.1)--a cross-sectional national survey that assesses health-related information among the Canadian population. To this end, we conducted a moderation analysis with problem gambling severity as the independent variable, weekly alcohol consumption as the moderator variable and suicidal ideations (in the past 12 months) as the dependent variable. The results found that alcohol consumption alone did not reliably predict suicidal ideation among gamblers who did not gamble problematically. However, as predicted, the odds of suicidal ideation were greatest among problem gamblers who frequently consumed alcohol. Thus, it may behoove policy makers to re-visit the availability of alcohol in gambling venues. Moreover, responsible gambling-oriented education initiatives may be advanced by informing gamblers about the increased risk of suicidal ideations when problematic gambling is combined with frequent alcohol consumption.

Creating symbolic cultures of consumption: an analysis of the content of sports wagering advertisements in Australia

BACKGROUND

Since 2008, Australia has seen the rapid emergence of marketing for online and mobile sports wagering. Previous research from other areas of public health, such as tobacco and alcohol, has identified the range of appeal strategies these industries used to align their products with culturally valued symbols. However, there is very limited research that has investigated the tactics the sports wagering industry uses within marketing to influence the consumption of its products and services.

METHOD

This study consisted of a mixed method interpretive content analysis of 85 sports wagering advertisements from 11 Australian and multinational wagering companies. Advertisements were identified via internet searches and industry websites. A coding framework was applied to investigate the extent and nature of symbolic appeal strategies within advertisements.

RESULTS

Ten major appeal strategies emerged from this analysis. These included sports fan rituals and behaviours; mateship; gender stereotypes; winning; social status; adventure, thrill and risk; happiness; sexualised imagery; power and control; and patriotism. Symbols relating to sports fan rituals and behaviours, and mateship, were the most common strategies used within the advertisements.

DISCUSSION/CONCLUSIONS

This research suggests that the appeal strategies used by the sports wagering industry are similar to those strategies adopted by other unhealthy commodity industries. With respect to gambling, analysis revealed that strategies are clearly targeted to young male sports fans. Researchers and public health practitioners should seek to better understand the impact of marketing on the normalisation of sports wagering for this audience segment, and implement strategies to prevent gambling harm.

Suicide Ideations, Suicide Attempts, and Completed Suicide in Persons with Pathological Gambling and Their First-Degree Relatives

We examined the relationship between suicidal ideations and attempts in 95 probands with pathological gambling (PG), 91 controls, and 1075 first-degree relatives. The results were analyzed using logistic regression with generalized estimating equations. Thirty-four PG probands (35.8%) and 4 controls (4.4%) had attempted suicide (OR = 12.12, p < .001); in 13 probands, the attempt occurred before PG onset. Lifetime suicidal ideations occurred in 60 PG probands (63.2%) and 12 controls (13.2%) (OR = 11.29, p < .001). Suicidality in PG probands is a marker of PG severity and is associated with greater psychiatric comorbidity. Offspring of PG probands had significantly higher rates of suicide attempts than control offspring.

Suicidal ideation and familicidal-suicidal ideation among individuals presenting to problem gambling services: a retrospective data analysis

BACKGROUND

Studies have consistently reported high rates of suicidal ideation (SI) among individuals with disordered gambling. None have explored gambling-related familicidal-suicidal ideation (FSI).

AIMS

This study examined the (1) prevalence of SI and FSI among treatment-seeking gamblers in Hong Kong, (2) characteristic profile of factors associated with SI and FSI, and (3) factors that predict SI and FSI.

METHOD

This is a retrospective analysis of data collected at initial clinical assessments from a specialized gambling counseling centre in Hong Kong. Participants were gamblers (N = 3,686) who sought treatment at the centre between 2003 and 2012. Information about socio-gambling demographics, physical and mental health status, current presenting problems, self-rated South Oaks Gambling Screen (SOGS, Chinese version), and occurrence of SI or FSI were examined. Descriptive analysis and ordinal regression analysis were used to investigate the characteristics of the gamblers and the association of variables.

RESULTS

In our sample, 720 (20.0%) individuals reported SI, and 22 (0.6%) individuals reported FSI at the initial assessment. Individuals with SI and FSI differed from the nonsuicidal individuals in terms of their demographics, gambling experiences and severity, mental and physical wellbeing, and types of gambling-related problems. The adjusted ordinal regression model shows that participating in table games in casinos and having familial and financial problems seem to enhance the likelihood of having SI and FSI.

CONCLUSION

While mental health issues are significantly related to SI and FSI among gambling treatment seekers, the impacts of physical, family, and financial strains should not be underestimated.

Gender differences in the associations of gambling activities and suicidal behaviors with problem gambling in a nationally representative French sample

INTRODUCTION

The objectives of the present study are to describe gender differences in factors associated with moderate risk and problem gambling.

METHOD

Data were extracted from the 2010 Health Barometer, a large survey on a representative sample of the general population aged 15-85 years living in France (n=27,653), carried out by the National Institute for Health Promotion and Health Education. Data were collected between October 2009 and July 2010. A computer-assisted telephone interview system was used.

RESULTS

The findings indicate that men are three times more likely to experience problems with gambling. Men and women have different patterns of gambling activities. Men were more involved with Rapido, internet gambling, sports and racetrack betting, poker, and casino tables, whereas women gambled more often on scratch games. Both men and women engaging in immediate reward games were significantly more likely to experience difficulties with gambling. This association, however, was stronger in women. Furthermore, suicidal ideation and behaviors were more likely to be associated with gambling problems in women as compared to men.

CONCLUSIONS

The study underscores the importance of considering gender-related differences in the study of gambling behaviors.

Suicidal ideation and suicide attempts in five groups with different severities of gambling: Findings from the National Epidemiologic Survey on Alcohol and Related Conditions

BACKGROUND AND OBJECTIVES

Problem and pathological gamblers show high rates of suicidal behavior. However, previous research of suicide among this population has been inconsistent. Discrepancies may stem from methodological issues, including variable use of suicide nomenclature and selection bias in study samples. Furthermore, earlier research has rarely examined gambling severity aside from problem or pathological categories. This study utilized subgroups derived from a nationally representative data set, examining different characteristics of suicidal behavior and several gambling levels, including subclinical groups.

METHODS

Participants included 13,578 individuals who participated in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and provided information on gambling behavior, lifetime suicidal ideation, and/or lifetime suicide attempts. Five gambling groups were derived using DSM-IV criteria for pathological gambling; non-gambling, low-risk gambling, at-risk gambling, problem gambling, and pathological gambling.

RESULTS

Problem gambling was associated with suicidal ideation [adjusted odds ratio (AOR) = 1.64, 95% confidence interval (CI) = 1.19-2.26] and suicide attempts [(AOR) = 2.42, 95% (CI) = 1.60-3.67] after adjustment for sociodemographic variables. Pathological gambling was associated with suicidal ideation [(AOR) = 2.86, 95% (CI) = 1.98-4.11] and suicide attempts [(AOR) = 2.77, 95% (CI) = 1.72-4.47) after adjustment for sociodemographic variables.

DISCUSSION, CONCLUSIONS, AND SCIENTIFIC SIGNIFICANCE

Our results from this population sample reinforce increased rates of suicidal behavior amongst smaller, clinical samples of problem and pathological gamblers. Education for providers about gambling is recommended, including screening for gambling-related symptoms such as suicidal behavior.

Weekly lottery sales volume and suicide numbers: a time series analysis on national data from Taiwan

OBJECTIVE

To investigate the association between weekly lottery sales and number of suicide deaths in Taiwan.

METHODS

All suicides aged 15+ years during 2004-2006 in Taiwan were included. Poisson autoregression time series models investigated associations of weekly numbers with contemporaneous and recent sales from two national lotteries in operation. Adjustments were made for seasonal fluctuation, temperature, monthly unemployment and autocorrelation.

RESULTS

In fully adjusted models, suicide deaths were negatively correlated with sales of tickets for a low-prize, low-cost lottery system. However, they were correlated positively with recent sales for a higher-cost, larger-prize system. Both correlations were stronger for male than female suicide numbers but differed in terms of age groups most strongly implicated.

CONCLUSIONS

Associations between lottery sales and suicide numbers differed according to the nature of the lottery. A low-prize, low-publicity system appeared to be more benign than a high-prize, high-publicity one.

[To an integrative management of pathological gamblers]

INTRODUCTION

Recent researches on pathological gambling indicate that the various gambling activities are heterogeneous by nature. Indeed, some findings support the view that gambling cannot be seen as a homogeneous activity. Therefore, pathological gamblers do not represent a homogeneous population. However, treatment does not appear to take into account this heterogeneity and studies in the field have assessed the efficacy of the various types of treatment. Furthermore, recent empirical data emphasize the need for delineating distinct subtypes of pathological gambling presenting similar symptoms but which, at the same time, differ on certain variables. These subtypes will be essential in the management, treatment, and prognosis of pathological gambling.

LITERATURE FINDINGS

Blaszczynski and Nower (2002) identified three subtypes of gamblers. The first subtype, referred to as the "emotionally vulnerable problem gamblers", includes gamblers who mainly gamble to escape painful emotional experiences. The second includes "antisocial impulsivist problem gamblers" who are mainly driven by impulsivity and sensation seeking. The last one, referred to as the "behaviourally conditioned problem gamblers", includes gamblers who gamble because of behavioural contingencies offered by the game, rather than psychological difficulties. Each group is characterized by specific psychological variables, and each may require a different treatment approach. Hence, these subgroups should be used and taken into account in the choice of the treatment.

AIM OF THE PAPER

The purpose of this article is to provide an integrative model of treatment of this disorder based on the typology of pathological gamblers. Many studies have tried to understand this pathological behaviour by exploring motivational, psychological, biological and ecological correlates of gambling to explain the aetiology. An approach integrating various orientations, at the same time cognitive-behavioural, motivational, psychoanalytical and bodily-centred is the most relevant for this behavioural disorder. On the one hand, treatment should focus on the similarities displayed by the gambler. On the other hand, treatment should evaluate and focus on the specificities of each subtype of pathological gamblers. This last point refers to the question of the role played by the game for the gambler. All pathological gamblers present similar symptoms. Concerning those common points, professionals should evaluate and treat comorbidities, wrong perceptions/cognitions, motivation to change, gambling behaviour and social aspects of the gambling behaviour. Concerning the specificities, professionals should evaluate to which subtype or pathway the gambler corresponds, and then adapt the treatment. For example, for emotionally vulnerable problem gamblers gambling to escape painful emotional experiences and presenting alexithymia components, specific psychotherapeutic techniques improving affect identification and differentiation should be applied. Thus, add-on individual psychoanalytical oriented sessions and relaxation sessions should be included in the treatment.

Sadness, suicide, and their association with video game and internet overuse among teens: results from the youth risk behavior survey 2007 and 2009

We investigated the association between excessive video game/Internet use and teen suicidality. Data were obtained from the 2007 and 2009 Youth Risk Behavior Survey (YRBS), a high school-based, nationally representative survey (N = 14,041 and N = 16,410, respectively). Teens who reported 5 hours or more of video games/Internet daily use, in the 2009 YRBS, had a significantly higher risk for sadness (adjusted and weighted odds ratio, 95% confidence interval = 2.1, 1.7-2.5), suicidal ideation (1.7, 1.3-2.1), and suicide planning (1.5, 1.1-1.9). The same pattern was found in the 2007 survey. These findings support an association between excessive video game and Internet use and risk for teen depression and suicidality.

Prevalence, clinical correlations, comorbidities, and suicidal tendencies in pathological Korean gamblers: results from the Korean Epidemiologic Catchment Area Study

OBJECTIVE

Based on the National Epidemiological Survey of Psychiatric Disorders in South Korea conducted in 2006, we examined the prevalence, clinical correlations, comorbidities, and suicidal tendencies of pathological gamblers in the community.

METHOD

Of the 6,510 participants who completed the Korean version of the Composite International Diagnostic Interview (K-CIDI) administered by trained lay interviewers, 5,333 subjects fully completed the Diagnostic Interview Schedule (DIS) exploring pathological gambling. The DIS has 13 items mapping to 10 criteria. Endorsement of five DSM-IV criteria was considered to reflect pathological gambling, and we considered endorsement of one to four criteria to indicate problem gambling. The frequencies of psychiatric disorders and suicidal tendency were analyzed among pathological/problem gamblers in comparison with controls; both odds ratios and significance levels were calculated.

RESULTS

The lifetime prevalence rates of pathological gambling and problem gambling were 0.8% and 3.0%, respectively. Of pathological gamblers, 79.1% had at least one psychiatric illness in comparison to the control level of 28.1%, and 62.0% of problem gamblers also had psychiatric conditions. Associations between pathological/problem gambling and alcohol use disorder, nicotine dependence, mood disorder, anxiety disorder, and suicidality were overwhelmingly positive and significant (p < 0.05), even after controlling for age and gender. Male gender, divorced/separated/widowed marital status, and urban living were all associated with increased risks of pathological and problem gambling (p < 0.05).

CONCLUSION

Pathological/problem gambling is highly associated with substance abuse, mood and anxiety disorders, and suicidality, suggesting that clinicians should carefully evaluate and treat such psychiatric disorders in gamblers.

Differential associations between problem and pathological gambling and psychiatric disorders in individuals with and without alcohol abuse or dependence

BACKGROUND

Alcohol abuse and/or dependence, alcohol use disorders (AUDs), and problem and/or pathological gambling (PPG) frequently co-occur with each other and other psychiatric disorders. However, prior studies have not investigated the relative influence of AUDs on the associations between PPG and other psychiatric disorders,

METHODS

Nationally representative data froni the National Epidemiologic Survey on Alcohol and Related Conditions (n=43,093; United States residents > or = 18 years of age) was used to examine the influence of AUDs on the associations between gambling and other psychiatric disorders and behaviors. The main outcome measures were co-occurrence of past-year AUD and Axis I and II disorders and severity of gambling based on the 10 inclusionary diagnostic criteria for pathological gambling.

RESULTS

Among non-AUD respondents, increasing gambling severity was associ- ated with increasingly elevated odds for the majority of Axis I and II disorders. Among AUD respondents, this pattern was typically not observed. Alcohol-by-gambling-group interactions for PPG were also found and the odds of these disorders was significantly increased in non-AUD respondents with PPG, but either unchanged or significantly lower in AUD respondents with PPG.

CONCLUSIONS

Gambling-related associations exist with multiple psychiatric disorders, but particularly in those without AUD. These associations have important implications with respect to conceptualization, prevention, and treatment of psychiatric disorders in individuals with gambling and/or AUDs.

Severity of gambling is associated with severity of depressive symptoms in pathological gamblers

The objective of this study was to investigate the relationship between gambling severity and depressive symptoms in pathological gamblers addicted to slot machines, with the hypothesis that comorbid depressive symptoms are associated with exacerbated gambling symptoms and behavior. Twenty controls and 20 pathological gamblers with different levels of depressive symptoms were studied during slot machine gambling. We found exacerbated gambling behavior in gamblers with high compared to low levels of depressive symptoms in terms of self-reported gambling urge (P < 0.01) and excitement from gambling (P < 0.05), number of games played (P < 0.01), and duration of gambling (P < 0.05). A correlation between depressive and gambling symptoms was found (r = 0.602, P < 0.01), thereby questioning which symptoms contribute to the exacerbated gambling behavior. Regression analyses showed that the symptoms influenced gambling behavior albeit in different ways. Although gambling symptoms predicted the rate of games played (P < 0.001), depressive symptoms predicted gambling urge (P < 0.01) and duration of gambling (P < 0.05). We discuss whether gambling symptoms only co-occur with other disorders; the need to look beyond the classification of pathological gambling as an impulse control disorder; and the potential role of anhedonia in depressed gamblers.

Conceptualizing and treating problem gambling as a family issue

Few family therapists have training in the identification, assessment, and treatment of problem gambling and its impact on couple and family relationships. The authors conceptualize problem gambling (PG) as a family issue and encourage clinicians and researchers to pay attention to the systemic antecedents and consequences of PG on family relationships. A review of the literature and clinicians' experiences regarding the impact of PG on couple and family relationships are presented and discussed. In light of the limited systemic-based treatments for PG, marriage and family therapists are urged to begin paying attention to this emerging issue that has significant couple and family ramifications.

Should gambling be included in public health surveillance systems?

This paper examines the question of whether indicators of pathological or disordered gambling should be included in current public health surveillance systems. Such inclusion can be justified in terms of the emerging associations between disordered gambling and the leading indicators of the risk for premature morbidity and mortality. Additional justification can be seen in terms of the potential of Internet gambling to increase the incidence of gambling disorders, particularly among younger and older populations. The paper describes characteristics of public health surveillance systems and recommends including gambling in such systems, on at least a provisional basis.

Psychometric properties of the inventory of gambling situations with a focus on gender and age differences

Environmental, interpersonal, and psychological factors contribute to gambling, but no standardized instrument for assessing high-risk gambling situations exists. This study evaluates the factor structure of the Inventory of Gambling Situations (IGS), a newly developed measure to examine situations that precipitate gambling. Pathological gamblers (n = 233) beginning a treatment study completed the IGS. Principal component analysis revealed that a 5-factor solution best fit the data, representing items related to Negative Affect, Luck and Control, Positive Affect, Social Situations, and Gambling Cues. Overall, Cronbach alpha was 0.960, ranging from 0.820 to 0.935 for the 5 factors. IGS scores correlated with other indices of gambling problems. Women scored higher on the Gambling Cues factor than men, and younger respondents, regardless of gender, scored higher on the Luck and Control factor than older respondents. The IGS may assist in better understanding situations in which pathological gamblers wager, and individual differences with respect to these situations.

Epidemiological associations between gambling behavior, substance use & mood and anxiety disorders

OBJECTIVE

To compare gambling behaviors in a random sample of community residents with and without mental disorders identified by the Composite International Diagnostic Interview (CIDI).

METHOD

A large national community survey conducted by Statistics Canada included questions about problems arising from gambling activities as per the Canadian Problem Gambling Index (CPGI). We compared respondents within three gambling severity categories (non-problem, low severity and moderate/high severity gambling) across three diagnostic groupings (mood/anxiety disorders, substance dependence/harmful alcohol use, no selected psychiatric disorder).

RESULTS

Of the 14,934 respondents age 18-64 years who engaged in at least one type of gambling activity in the previous 12 months, 5.8% fell in the low severity gambling category while 2.9% fell in the moderate/high severity category. Females accounted for 51.7% of the sample. The risk of moderate/high severity gambling was 1.7 times higher in persons with mood or anxiety disorder compared to persons with no selected disorder. For persons with substance dependence or harmful alcohol use, the risk of moderate/high severity gambling was 2.9 times higher. Persons with both mood/anxiety and substance/alcohol disorders were five times more likely to be moderate/high severity gamblers. The odds ratio for females was 0.6 and for those with less than post-secondary education it was 1.52. Differences in age and personal income were not significant.

CONCLUSIONS

Individuals in the community suffering from mood/anxiety disorders and substance dependence/harmful alcohol, and especially those with both, experience a higher risk for gambling problems. The treatment of these comorbidities should be integrated into any problem gambling treatment program.

The association between pathological gambling and attempted suicide: findings from a national survey in Canada

OBJECTIVE

To examine the association between pathological gambling (PG) and attempted suicide in a nationally representative sample of Canadians.

METHODS

Data came from the Canadian Community Health Survey, Cycle 1.2, conducted in 2002, in which 36 984 subjects, aged 15 years or older, were interviewed. Logistic regression was performed with attempted suicide (in the past year) as the dependent variable. The independent variables were PG, major depression, alcohol dependence, drug dependence, and mental health care (in the past year), as well as a range of sociodemographic variables. Survey weights and bootstrap methods were used to account for the complex survey design.

RESULTS

In the final logistic regression model, which included terms for PG, major depression, alcohol dependence, and mental health care, as well as age, sex, education, and income, the odds ratio for PG and attempted suicide was 3.43 (95% confidence interval, 1.37 to 8.60).

CONCLUSIONS

PG (in the past year) and attempted suicide (in the past year) are associated in a nationally representative sample of Canadians. However, it is not possible to say from these data whether this represents a causal relation.

Examining the relationship between at-risk gambling and suicidality in a national representative sample of young adults

Although many clinical studies document a relationship between gambling and suicidality, evidence of this association in general population surveys has been mixed. Probing this association in a nationally representative sample of young adults with data from the National Longitudinal Survey of Adolescent Health, we made same gender comparisons of depression and suicidality between 298 at-risk gamblers and 13,000 others. Although gamblers of both genders showed higher depression, only females reported significantly higher suicide thoughts and attempts. Males with gambling problems were no more likely than nongamblers to have suicide thoughts or to make prior suicide attempts on three separate measurement occasions.

A comment on the utility of prevalence estimates of pathological gambling

The case is presented that researchers interested in policy aimed at treating the pathological gambler need to shift focus to improving the utility of prevalence estimates. It is argued that researchers supplement prevalence estimates with practical and well-defined measures of severity and other predictors and correlates of help-seeking. The dimension of severity is emphasized as one means of providing estimates that are relevant to policy makers when placed in the context of additional measures that improve their meaning and utility. Estimates may then be partitioned along these dimensions to ascertain the proportion of gamblers most likely to need or seek treatment for gambling-related disorders. The recommendations provided are subject to a number of possible objections and are presented in the interest of stimulating further discussion such as the distinction between symptom assessment and the measurement of severity.

Risk Factors for Suicide Ideation and Attempts Among Pathological Gamblers

The link between pathological gambling and suicide is poorly understood. The current study has two major goals: to provide descriptive information about suicide ideation and attempts among pathological gamblers trying to quit, and to identify predictors of suicidal ideation and attempts, with a particular emphasis on mood and substance use disorders. A community sample of 101 individuals with gambling problems who had made a recent quit attempt was assessed using structured instruments. Of these, 28.7% reported no history of suicide ideation or attempts, 38.6% reported having only thoughts of suicide, and 32.7% reported a suicide attempt. Ideation predated the onset of gambling problems by an average of greater than ten years. History of ideation was increasingly likely with a greater severity of gambling problem as determined by DSM criteria. Those experiencing ideation were also more likely to over gamble on gambling days and five times more likely to have a history of depression. Substance abuse history was the only factor that distinguished between individuals who had a history of suicide attempts versus ideation only. Having a drug history was related to a more than six times greater likelihood of having made a suicide attempt. Gambling-related suicide attempts were relatively rare-21.2% of attempters, or 7% of the total sample. These findings are consistent with the common factor model of etiology in which the suicidality of gambling is related to prior mental health disorders. More research on the relationship between alcohol and other drug disorders and their complex relationship to pathological gambling and suicide is crucial.

Variations in the prevalence of psychiatric disorders and social problems across Canadian provinces

OBJECTIVE

To determine provincial 12-month prevalence rates for selected psychiatric disorders and to assess the association between these and the Canadian Social Problem Index (SPI).

METHOD

Psychiatric data for depression, mania, panic disorder, social phobia, and agoraphobia were derived from the results of the 2002 Canadian Community Health Survey: Mental Health and Well-Being. The Canadian SPI was updated for 2002, and correlations were calculated between the SPI and the 5 diagnostic prevalence values across provinces.

RESULTS

The results showed that the SPI had maintained its tendency to increase from east to west in Canada, a trend reflected by depression and mania. The psychiatric disorders did not show strong correlations with the SPI in 2002, but depression and mania did show relatively strong associations with index values from earlier years. High-to-low ratios across provinces for individual social problems averaged over 5, and the results were essentially of the same magnitude for the ranges of particular psychiatric diagnoses.

CONCLUSIONS

The differences in need found here suggest that per capita allocation of funding for mental health and social programs may not be appropriate. The mixed findings on the association between mental disorders and social problem behaviour across provinces leads to more research questions than research answers.